📚 Osteopathic Exam Revision

Pregnancy & Pelvic Pain

Case 1 — A complete osteopathic case study guide from history to treatment

🤰 32-year-old female · 28 weeks pregnant · Right-sided pelvic pain
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Examiner's Focus — Key Points to Demonstrate

Screen all red flags before any treatment
Obtain obstetric history & gestational age
Modify examination for pregnancy safety
Justify technique choice & contraindications
Demonstrate clear clinical reasoning
Discuss multidisciplinary referral pathways

Case Study Breakdown

Six key stages — each a focused revision card for your exam

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Stage 01
Case History
  • 32-year-old female, G2P1, 28 weeks gestation
  • Right-sided pelvic & groin pain, onset 2 weeks ago
  • Pain worsens with walking, climbing stairs, turning in bed
  • Mild lower back ache; no urinary symptoms or bleeding
  • Previous pregnancy: mild SPD, resolved postpartum
  • Occupation: primary school teacher (prolonged standing)
  • Midwife aware; last antenatal check 3 weeks ago — normal
  • No trauma, fever, or systemic illness reported
  • Pain score: 5–6/10 at worst; eased by rest
🚩
Stage 02
Red Flags & Differentials
  • Red Flag Vaginal bleeding or fluid loss → refer immediately
  • Red Flag Fever, rigors, dysuria → UTI / pyelonephritis
  • Red Flag Severe unilateral pain + nausea → ectopic (earlier) / appendicitis
  • Red Flag Regular uterine contractions → preterm labour
  • Red Flag Reduced fetal movement → obstetric emergency
  • Differential Symphysis Pubis Dysfunction (SPD / PGP)
  • Differential Sacroiliac joint dysfunction
  • Differential Round ligament pain (sharp, brief, positional)
  • Differential Lumbar disc pathology / nerve root irritation
  • Differential Ovarian cyst / fibroid (less likely at 28 wks)
🔍
Stage 03
Assessment & Examination
  • Observation: Antalgic gait, lateral trunk shift, increased lumbar lordosis
  • Active movement: Reduced hip flexion & abduction on right; pain on weight-bearing
  • Palpation: Tenderness over right SIJ, PSIS, and pubic symphysis
  • ASLR test: Positive right — indicates load transfer deficit
  • Posterior Pelvic Pain Provocation (P4): Positive right SIJ
  • FABER / Patrick's test: Positive right — SIJ & hip involvement
  • Gaenslen's test: Positive — SIJ provocation confirmed
  • Neurological screen: Sensation, reflexes, power — all intact
  • Avoid: Prone position, supine >3 min, high-velocity lumbar thrust
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Stage 04
Working Diagnosis
  • Primary Right-sided Sacroiliac Joint Dysfunction (Pelvic Girdle Pain)
  • Relaxin-mediated ligamentous laxity increases SIJ mobility
  • Altered biomechanics & weight distribution in 3rd trimester
  • Occupational load (prolonged standing) as aggravating factor
  • Previous SPD history increases recurrence risk
  • No neurological compromise — musculoskeletal origin confirmed
  • No obstetric red flags identified at this stage
  • Prognosis: Good with conservative management; typically resolves postpartum
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Stage 05
Technique & Treatment Plan
🔑 Primary Technique: MET to Right SIJ (Side-lying) Patient side-lying (left side down), pillow between knees. Engage SIJ barrier, patient resists hip extension for 5–7 sec, relax & take up new barrier. Repeat ×3.
  • Soft tissue: Lumbar paraspinals, gluteus medius & piriformis (side-lying)
  • Articulation: Gentle SIJ & hip mobilisation within pain-free range
  • Counterstrain: Tender point release — PSIS & iliacus
  • Diaphragm release: Seated — improves thoracolumbar fascial tension
  • Craniosacral: Sacral rocking — gentle, well-tolerated in pregnancy
  • Avoid: HVLA lumbar/pelvic thrust, prone techniques, deep abdominal work
  • Frequency: Weekly for 4 weeks, then reassess
  • Home advice: Pelvic girdle support belt, sleep with pillow between knees
🛡️
Stage 06
Safety & Patient Management
  • Obtain written informed consent — explain pregnancy-specific risks
  • Communicate with midwife / obstetrician before & after treatment
  • Monitor for red flags at every session — document findings
  • Avoid supine position >3 min (aortocaval compression risk)
  • Use semi-reclined or left lateral position as alternatives
  • Advise patient to report any contractions, bleeding, or reduced fetal movement immediately
  • Refer to physiotherapy for pelvic floor assessment & exercise programme
  • Ergonomic advice: Limit standing, use supportive footwear, avoid asymmetric loading
  • Postpartum: Reassess at 6–8 weeks; address any residual dysfunction
  • Document all clinical decisions with clear reasoning in patient notes

⚡ Exam Quick-Fire Reminders

Relaxin EffectPeaks in 1st trimester, remains elevated throughout — increases all joint laxity, not just pelvis
ASLR TestGold standard for PGP — tests ability to transfer load through pelvis; positive = impaired transfer
MET RationalePost-isometric relaxation reduces muscle guarding around SIJ; safe & effective in pregnancy
Aortocaval RiskUterus compresses IVC in supine after ~20 weeks → hypotension, reduced placental flow